Late-onset bilateral lens dislocation and glaucoma associated with a novel mutation in FBN1

Purpose To describe the clinical and genetic findings in one Chinese family with late-onset bilateral lens dislocation and secondary glaucoma. Methods One family including three affected members and 16 unaffected family members was examined clinically. After informed consent was obtained, genomic DNA was extracted from venous blood of all participants. Linkage analysis was performed with two microsatellite markers around the fibrillin-1 (FBN1) gene (D15S992 and D15S126). Mutation screening was performed using direct DNA sequence analysis and single strand conformation polymorphism (SSCP). Results Clinical examination and pedigree analysis revealed that four members in three generations were affected by late-onset lens dislocation and secondary glaucoma but had no signs of cardiovascular abnormality or abnormal skeletal features. By genotyping, the family showed the linkage to FBN1 on 15q21.1. After mutation screening analysis on 65 exons of FBN1, a novel heterozygous missense mutation, c.2860C>T (R954C), was detected. This mutation cosegregated with the disease phenotype in the family and was not found in 100 normal controls. Conclusions Late-onset isolated ectopia lentis with secondary glaucoma is consistent with a novel mutation in FBN1. Our finding expands the spectrum of FBN1 mutations and is useful for further genetic consultation and genetic diagnosis.

Here, we reported a Chinese family associated with lateonset isolated EL and secondary glaucoma. Molecular genetic analysis of the family revealed a novel heterozygous missense mutation in FBN1.

METHODS
Patients and DNA samples collection: This study was approved by the Beijing Tongren Hospital Joint Committee on Clinical Investigation. After informed consents were obtained, all participants underwent physical, ophthalmologic, and cardiovascular examinations. Ophthalmologic examinations included bilateral visual acuity, slit-lamp biomicroscopy, fundus examination with dilated pupils, and ultrasound biomicroscopy (UBM). Cardiovascular examinations included electrocardiogram and echocardiogram. Peripheral blood was obtained by venipuncture, and genomic DNA was extracted according to standard protocols. Linkage analysis: Genotyping and linkage analysis were performed with two microsatellite markers, D15S992 and D15S126, around FBN1. Their detailed genetic and physical distances are shown in Figure 1. The primer sequences of D15S992 and D15S126 were obtained from the The GDB Human Genome Database. Genotyping and linkage analysis were performed as described elsewhere [11,12]. LOD scores were calculated for the two markers by two-point linkage analysis using linkage package 5.2. We modeled the disease as an autosomal dominant trait with reduced penetrance. Pedigree and haplotype were constructed using Cyrillic V. 2.0 software.
Mutation screening of FBN1: The whole coding region of FBN1 was amplified by polymerase chain reaction (PCR) from genomic DNA. Sixty-five pairs of primers for FBN1 were used according to the articles previously published [13,14]. Nucleotide sequences were compared with the published cDNA sequence of FBN1 (GenBank accession number NM_000138) using DNAssit version 1.0. Single strand conformation polymorphism: Single strand conformation polymorphism (SSCP) was used to exclude the point mutations from the normal controls. PCR amplified DNA fragments were mixed with an equal volume of formamide buffer and electrophoresed on a 12% nondenaturing polyacrylamide gel (12 ml 30% PAGE [acrylamide:bisacrylamide=29:1]; 3 ml 10X TBE; 15 ml distilled water; 600 μl 10% ammonium persulfate, 5 μl tetramethylethylenediamine). After electrophoresis, gels were silver-stained and analyzed.

Clinical findings:
We have identified a Chinese family with bilateral lens dislocation. The mode of inheritance was autosomal dominant (Figure 1). The family had 20 individuals; four of them were affected (one male and three females). As the mother of the proband passed away several years ago, we did not get her blood sample. However, from her hospital records, we inferred that she suffered the same eye disease. After clinical examinations and reviewing hospital records, we found all affected members shared almost the same clinical manifestations. All of them first experienced the sudden blurring of vision with periocular pain and congestion, then ophthalmologic examinations showed high intraocular pressure (IOP; 40-80 mmHg), corneal edema, shallow anterior chamber, and lens dislocation. All affected members underwent lens extraction, and their IOP were in the normal range after surgery. Fundus examination for three of the affected individuals showed healthy and pink optic discs with a cup/disc ratio around 0.4 (except the proband's right eye). Physical and cardiovascular examinations presented no skeletal and cardiovascular features of MFS in any of the affected members. Their detailed clinical information is summarized in Table 1.
Genotyping results: This family with isolated EL was genotyped with two microsatellite markers located around FBN1 in the 15q21.1 region. The marker results for D15S992 and D15S126 were fully informative for linkage. Haplotypes were constructed for this family to determine whether the disease was segregating with microsatellite markers. For this family, there were no affected recombinants for either of the two markers ( Figure 1). Interestingly, three clinical unaffected individuals (III:1, III:6, and III:7) inherited the affected haplotype as well. As the lens luxation in this family seemed to represent a late-onset feature in the phenotype and all three of them were under 37 years old (the youngest age of onset in this family), they were obligate carriers. Their detailed clinical information was also summarized in Table 1. Therefore, the disease penetrance appeared incomplete in this pedigree. Two-point LOD scores for D15S992 and D15S126 with 60% penetrance were 0.70 (θ=0.0) and 2.36 (θ=0.0), respectively. Mutation analysis: By direct sequencing the 65 exons of FBN1, we identified a novel base change, C>T, at position 2860 of cDNA, replacing arginine acid with cysteine at codon 954 ( Figure 2A). Using SSCP analysis, this heterozygous mutation cosegregated with all affected members and affected haplotype carriers in this Chinese family ( Figure 2B) but was not detected in 100 unrelated normal controls.

DISCUSSION
In this study, we analyzed a Chinese family with four members affected by lens dislocation along with secondary glaucoma. By genotyping, the family showed the linkage to the EL locus on 15q21.1. One novel heterozygous FBN1 mutation, R954C, was identified in this family. The mutation, R954C, was found to cosegregate with the EL phenotype, and where three clinically unaffected members carried the mutation, they were also found to harbor the affected haplotype. This variant was not detected in 100 normal control individuals. All affected individuals showed ocular involvement only and did not meet the Ghent criteria for Marfan syndrome [6]. Diagnosis of isolated ectopia lentis was established for this family. In our review of the literature, isolated EL occurs either as a congenital disorder or as a spontaneous disorder of late onset, which is between the ages of 20 and 65 years [1,7,15]. This family's late-onset feature (37-51 years old) is in accordance with the secondary condition. As three obligate carriers in this family were still younger than 37 years old (the youngest age of onset in this pedigree), they might develop EL in the future or present reduced penetrance or non-penetrance as reported before [7,15]. They should therefore undergo ophthalmologic surveillance at regular intervals throughout their lives.
To date, over 600 mutations in FBN1 have been reported. However, mutations for isolated EL only take a small part (FBN1 Universal Mutation Database [UMD]). Mutation R954C that was detected in this study is the first missense mutation in exon 24 associated with isolated EL. Mutations within the middle region (exons 24-32) of FBN1 are usually associated with a severe form of MFS, neonatal MFS, and define a high-risk group for cardiac manifestations [5][6][7][8]16]. Mutation R954C is located in the third 8-Cys/TB modules, which contains eight cysteine residues that form four disulfide bonds-between C1 and C3, C2 and C6, C4 and C7, and C5 and C8. This mutation adds a new cysteine residue, which  1. CLINICAL DETAILS OF THREE AFFECTED MEMBERS AND THREE CARRIERS IN THE ECTOPIA LENTIS FAMILY.   II:1  II:8  II:11  III:1  III:6  III:7  Age  67  61  49  36  34  21  Onset age  37  54  ?

Skeletal features
Height (cm)  168  160  165  174  165  162  Pectus carinatum - R represents right eye; L represents left eye; + represents positive syndrome; -represents negative syndrome; ? represents syndrome is unknown; LP represents light perception; LE represents lensectomy; PI represents peripheral iridotomy; CL represent corneal leukoma; ILS represent intraocular lens suspension; The asterisk indicates that the lens was completely dislocated into the anterior chamber, which induced corneal endothelial decompensation and corneal opacity.
might destroy the disulfide bond formation and further influence the structure and function of fibrillin-1.
Early in 2002, [17] Comeglio et al. noted that mutations involving non-conserved arginine to cysteine substitution are usually associated with isolated EL. To date, nine of these types of substitutions have been identified in FBN1 (Table 2) [13,[17][18][19][20][21][22][23][24][25][26][27][28][29]. Seven of them including the one detected in this study definitively caused isolated EL, and the majority of them are confined to the first 15 exons of FBN1 (5/7). Our results support the prior suggestion that non-conserved arginine to cysteine substitution is highly related to predominant EL regardless of which modules they are located [17,18].
Another clinical feature of this family is glaucoma, which is relatively common and a serious complication of ectopia lentis [1]. According to the literature, glaucoma usually occurs more frequently in spontaneous late subluxation of the lens than in the congenital type [1]. We concluded that the pathogenesis of glaucoma in this family was due to lensinduced pupillary block.
In summary, we described a novel non-conserved arginine to cysteine substitution in exon 24 of FBN1 that is associated with late-onset isolated EL and secondary glaucoma. Our results further expanded the mutation spectrum of FBN1 and provided useful genetic consultation and genetic diagnosis for this family.